T I l E DUBLIN JOUIRN_A_L OF

M E D I C A L S C I E N C E .

MARCH 1, 1890.

PART I.

ORIGINAL COMMUNICATIONS.

AnT. V I I I . - - 0 n the Medical Selection of Lives for Assurance2 By ART~t:R WrNNE FOOT, M.D., Univ. DubI. ; President of the Section of State Medicine, in the Royal Academy of Medicine in Ireland; Senior Physician to the Meath Hospital; Fellow of the King and Queen's College of Physicians; Diplomate in State Medicine, Trin. Coll., Dubl., &c.

LIFE and fire are the objects in view of which assurances are now mostly effected. No longer are they, as formerly, negotiated against thieves, highwaymen, death from drinking Geneva, loss of female virtue, divorces, or making boards out of sawdust.

The early offices, it is true, charged enormous premiums owing to their not possessing reliable data for calculation; and perhaps they were not unreasonable in doing so, for some of their under- takings, if we may judge from the enumeration just given, were extremely hazardous, and involved risks not always avoidable.

The contract of life assurance is one based on a full knowledge by the insuring company of the health and habits of the person insured. Upon ~he selection of lives depends to a large extent tlm financial success of a Life Assurance Company. The duties of the medical examiner--on whom very largely depends this selectlon--are responsible, and in some respects peculiarly so. There may be no difficulty in at once coming to the conclusion that certain lives are

Road before the Section of State Medicine of the RoyM Academy of ~edielne in Ireland, on Friday, February 7, 1890. [For the discussion on this paper see page 269.]

YOL. L X X X I X . - - N O . 2 1 9 , THIRD SERIES. O

194 On the 3ledical Selection of Li~es for Assurance.

eligible, and that others are quite ineligible; but there is a large number of intermediate lives that will try the skill and tax the patience of the examiner, demand mature consideration, and involve further inquiries, before they can be finally disposed of.

I t is now universally admitted by all parties interested that the medical element constitutes an important item in the consideration of a proposal for life insurance. The medical examiner's relation to the proposer is different from that which he occupies in his ordinary professional capacity. In the latter case the patient exposes his infirmities, and even intensifies them ; the applicant for llfe assurance, on the other hand, may desire to lessen their importance, or conceal their existence. In fact the applicant for assurance stands in a relation the very reverse of that occupied by a patient. The latter comes for relief, and is ready to aid, as far as he can, in the discovery of his alhnent. The former approaches with the assumption of health, and {he examiner must detect unaided "any fallacies in that assumption; and it may so happen that the would-be assurer is a rogue, and his object and interest are to deceive.

The questions set forth for answer in the Proposal Form are sometimes regarded by medical examiners, not permanent officials of a company, as superfluous and vexatious. They are irritated by what seems the dictation to them of a special method of examina- tion, and resent the inquiries made by an office as an imputation upon their mode of reporting. They do not remember that the answers to these inquiries are preserved for reference, and that legal decisions have turned on their having or not having been asked and answered. These questions are also useful in suggesting subjects that a careless or over-busy practitioner might slur over or forget, and no matter how acute and vigilant a medical adviser may be, many points may elude his inquiry or observa- tion, owing to the necessary limits of time and space, as well as to the reticence, wilful or accidental, which many exercise on matters of health. I t may be laid down as a general rule that the best men give the most satisfactory and detailed reports, as they fully appreciate the aid they afford towards the development of a social scheme of the highest value and importance. ~ I t has long been settled law in these countries that any untrue answer to the questions devised by au assurance company to elicit the knowledge requisite for their contract vitiates the policy, and

Sieveking. The Medical Adviser in Life Assurance. 1874. P. 48.

]~y DR. A. W. Foo~. 195

discharges the company from their liability under it. So far from regarding tile present list of questions as vexatiously minute, I anticipate that before long assurance companies will not be satisfied without information as to the condition of the retina; the state of arterial tension ; the integrity of the various reflexes (superficial. deep, cranial, organic); the nutrition of nerve-flbres and muscles, as estimated by electricity; the centesimal excretion of urea; microscopical examination of urinary sediments; and a statement of the amount of respiratory capacity.

The regular employment of medical men to examine candidates for life assurance is a practice of comparatively recent date. The custom of the old o~ces, prior to about 1820, was for each life proposing to" sign a very distinct and binding declaration to the effect that the individual had not had "cow or small-pox, or any other disease tending to shorten life." No mention seems to have been made of family history. The proposer had to give a reference to " t w o persons of good repute, one, if possible, of the medical profession." Persons who did not appear before the directors, or who could not refer to a medical gentleman, were required to give a reference to three persons. ~ The disastrous consequences of dispensing with a medical examination was shown by the late Dr. Brintorr, who examined a number of insurances effected without medical examination. From three or four pages of these cases he collected no less "than forty instances of death from pulmonary consumption, at periods which averaged eighteen weeks from the date of effecting the policy, but often did not exceed three, four, or five weeks. The average loss to the company on these forty policies was exactly forty times the premiums paid. b I t is in the mortality from tubercular diseases--the very class which, under the old system, was the bane of assurance companies--that selection shows the most powerful influence in favour of the companies. Mr. Dovey ~ of the Standard Life Assurance Company, London, in a paper read before the Institute of Actuaries, shows that under the modern system, in the first year of assurance, the actual deaths from these diseases are less than the tenth of the computed number; in the second year the proportion increases to 27 per cent. ; in the third, to 52 per cent. of the computed mortality. After the third year, the proportion, although showing fluctuations, appears to

a Sieveking. Loc, cir. P. 43. b Brinton. Med. Select. of Lives for Assurance. 1836, 2nr eel. ~Assurance Magazine. ~rol. X X I I I . , p. 28~. 1881.

196 On tlte Js Selection of Li~,es for Assura~we.

settle down to an average of 60 per cent.--this ratio n~t showing any tendency to increase in the later years of assurance. Thus, after the "immediate effects of the medical examination have passed away, there remains a more permanent, though less strongly marked, influence in the selection of the mortality for a long series of years." This beneficial result may be due to different causes ; to the class selection of assured lives; to their increasing age ; to the number of predisposing causes which can be appreciated; and to the increased accuracy of skilled personal examination.

In reference to the list of questions asked on the Proposal Forms, there are some points which may be adverted to with advantage to the more inexperienced examiners. The conservatism with which insurance offices cling to the recognition of an apoplectic habit is singular, as it is well known there is no type of face or form characteristic of the conditions which lead to this catastrophe. The apoplectic habit, in as far as it is characterised by the con- junction of broad chest and shoulders and short neck, with a large abdomen, powerful muscular system, and a reddish face, is found absent in the majority of those who suffer from cerebral hsemor- rhage, and who are more often poorly nourished, lean, scraggy, long-necked persons. 1NTothnagel is inclined to think that the popular fear of apoplexy in one who may be short, stout, thick, and red, is based upon a confusion of this affection with cerebral hypersemia and its attendant symptoms. However, it is a very old belief that there is a particular conformation of body in those who are prone to attacks of apoplexy, the pattern being denoted by a large head and red face, short thick neck, and a stout, square, squat build of body. This opinion dates from the time of Hippocrates; its correctness has become doubtful to modern pathologists. Dr. Wilks repudiates it entirely. I t is probable that apoplexy--that is, cerebral hsemorrhage in consequence of disease of intra-cranial arteries--may befall any who are endowed with the antecedent arterial conditions, irrespective of their particular build of body. A more important fact to bear in mind is the undoubtedly hereditary character of apoplexy; " i t runs in families "--i.e., in an indirect way, in virtue of the inheritance of a tendency to arterial degeneration. The influence of heredity may induce a seizure at an earlier age than 40, before which age apoplexy otherwise rarely occurs. In 116 claims for apoplexy against the Scottish Widows' Fund, the youngest u had reached the ago of only 22. His father had died of the same disease at 66.

By DI~. A. W. FooT. 197

There is seldom any attention directed in the Proposal Forms to the existence of a discharge from the external ear, yet such a condition betokens incalculable dangers to the life of the individual who has such a symptom. The importance of attention to aural discharges, in regard of prognosis, was long ago insisted on in this city by Sir William Wilde, and it is not put too forcibly by Dr. l~atterson Gassells, * when he says that, for general guidance. it may be accepted as an axiom that, with an ear discharge-- whether moderate or copious in quantity, continuous or interrupted in its flow, short "or lon~ in its duration--so lo~ff as it exists, one cannot tell how, when, or where the case may terminate. He suggests that the question should be put to proposers, "Have you at any time suffered from an ear discharge ?"

Inquiries are seldom made as to whether the proposer is liable to attacks of erysipelas. Erysipelas is a disease of diminished vitality, and its" occurrence--especially if more than once--should be regarded with suspicion, particularly in those whose occupation exposes them to intemperate habits, or to sharp, cold winds. I was acquainted with an old clergyman who lived at Kingstown ; he lind seven annual attacks in succession of facial erysipelas, con- tracted periodically during the spring easterly winds. He died in the eighth attack with head symptoms. In the case of the Scottish Widows' Fund, Dr. Begbie found erysipelas had proved fatal in eight cases, and that it was associated, as a cause of death, particu- larly with disease of the brain and its membranes, and disorders of the liver and bowels. Considering the frequency of this association, the disposition of the disease to recur, and its connec- tion with depraved digestion and defective assimilation, Dr. Begbie was of opinion that those who have been affected with it cannot be considered as eligible subjects of life assurance."

Another matter which should not be overlooked is the occurrence of fmcal obstruction, especially if originating near the right iliac fossa. The applicant may deem it unworthy of mention, regarding it as constipation ; but many people are liable to a recurrence of obstruction, probably from some malformation or band of adhesion, and succumb eventually in the absence of the timely assistance which had rescued them on previous occasions.

The exact state of health at the time of insurance does not represent the whole of the risk incurred by an office. The restora-

a B. M. flour. Vol. I., p. 323. 1877. b Assur. Mag. Vo]. VII I . , p. 336.

198 On tlle llTedicc~l Selection of Lices for Ass~n'c~nce.

tion of health after an attack of pneumonia may be only temporary ; it may be speedily followed by phthisis. _A convalescent from rheumatic fever may hasten to get his life insured before the signs of valvular disease originating therefrom have become objective. A subject of winter cough may get hhnself accepted in midsummer, during his vestival intermission, and die of bronchitis early in the ensuing winter. A patient with angina peetoris might easily pass in an interval between the paroxysms. Some practi- tioners entertain the opinion that, provided they can certify that the applicant is in good healLh at or about the time of the insurance, this is all tile insurers need know. The same opinion is commonly held by the candidate, and a proposer, after having been attended by one medical man for an illness, will apply to another, a comparative stranger, to certify as to his condition of health for insurance. On this account the directors of a company require the applicant to furnish them with the names, if any, of his different medical attendants. Policies have been vitiated by the insured saying they had not had any medical attendant when they had, and verdicts given for the offices on the ground of fraud. ~ In the case of Maynard against the Pelican Life Office, Lord Tenterden remarked that to refer to one medical man whom the insured knew would speak well of his health, and not to others whom he knew could not report favourably (although the insured did not die of the disease for which they had attended him), would vitiate his policy. Similarly, for the insured to refer to a practi- tioner who had attended him three years previously, and to omit to mention one who had attended him more recently, or to refer the office to a practitioner who had attended him for many years for mere trivial complaints, and to omit one who had attended him, even though for a short period only, for a serious disease, would equally render the policy voidP

I t may here be worth remarking that, when a medical man is appealed to by an assurance office respecting the health of one of his patients desiring to insure--leaving the company out of the question--justice to the proposer, to his survivors, and to the medical man himself, demands that he should report without :~ shadow of concealment. Unless he is prepared to do this, he had far better decline to report altogether. Further, he is not justified in reporting as the private medical adviser of the person whose

Tidy. Legal Med. Par t I~ P. 397. b Tidy. Op. cir. I ). 373.

By Dm A. W. Foo~. 199

life is in question, unless he has the authority of his patient to d o SO.

The conscientious discharge, in this respect, of his duty by an examiner may lead to the interruption of life-long friendships. William Cnllen and Sir Robert Christison, two of the brightest lights of the :Edinburgh school, and indeed of the medical world of that time, were on such terms of intimate friendship as to be called les deux ins@arables. Cullen had a bad attack of apoplexy in Paris, so bad that Dr. Alison, who happened to be passing through Paris at the time, thought he could not recover. He, however, apparently made a good recovery, but about two years after his attack of apoplexy, one day when on duty in the hospital, he fell in a fit of epilepsy, in presence of a crowd of students. Every welMnformed physician knows that epilepsy .after apoplexy usually makeg short work with its victim--in two years commonly, or in three years, Cullen determined to marry, although he had had several subsequent fits at moderate intervals. Sir Robert Christison, in his Autobiography, ~ describes what happened : - -" On the occasion of his man'iage our frlendshipunderwent a severe trial, and did not withstand it. He (Cullen) had to insure his life for the benefit of his wife and family--and heavily for a young man at the Outset of life. I te referred to me, as his medical adviser and friend, for a certificate of eligibility. I certified that I knew nothing" to detract from the value of his life, except his notorious attack of apoplexy and his figs, ' of the nature of which I had not any personal knowledge, never having seen him in one.' He expressed great surprise and disappointment, pressed me very hard to alter the terms of my certificate, said gloomily that I had a much worse opinion of his case than he had ever dreamt of, and at length worked himself up to urge upon me that my opinion would put an end to his marriage. But as I was satisfied that a few years would end his life, I stood firm under this cruel trial ; and we parted, coldly on his part--and cold he remained ever after- wards. I had the satisfaction, however, of leanfing immediately that I was not only right, but likewise his best friend, for his principal trustee, who was also his agent, called on me on the subject, go~ my unreserved opinion, and, unlike Cullen himself, expressed great obligation to me for my firmness and frankness, because he had in vain tried to get at the bottom of the fits by referring even to those medical men who had witnessed them.

9~ Vols. 1885. Vol, I., p. 128.

200 On the 3[edical Selection of Lices fo~" Assistance.

' But now,' added he, ' the insurance directors are warned, I shall tell them they must take every means for satlsfying'themselves as to the nature of these fits; but that there must be no calling of the insurance in question hereafter on the ground of info~'mation being witMteld.' The result was tha t the physician of the insurance company--a pompous, conceited, superficial man--bin/self certified the fits as being of little or no moment, and the proposal was accepted for a merely nominal and trifling extra premium. Cullen had the folly to twit me with his success ; and the marriage--which never had been endangered, as his agent assured me, by this dit~iculty-- was carried through. But in about two years more the company had to pay s to the marriage trustees. Cullen died in a paroxysm; and Edinburgh medicine lost one of her most gifted and promising sons."

Consumption is, perhaps, of all the diseases from which selected 1;ives are known to suffer, the one to which most attention has been directed in medical statistics of life assurance, and a result of the increased vigilance of directors and their ofi%ers in avoiding con- sumptive risks is a very much lessened mortality from this cause. Consumption as a cause of death in the family record should never be overlooked by the examiner. I f it happens that brothers and sisters of the applicant have died in youth from lesions of the brain or abdominal organs, tuberculosis may be suspected as the cause of death, because among children tubercle generally attacks the brain and the cavity of the abdomen before it appears in the lungs. When the infant mortality in the family history has been great (generally entered in the proposal as died "young," " i n infancy," " i n child- hood," without any further particulars), and the surviving members, including the applicant, are quite young, or he is the only survivor, the risk is very hazardous. I t is a sound principle of action in life assurance to recommend the rejection of a life when so many as two immediate relatives are admitted to have died of consumption. The mortality from phtlaisis is far more due to its undoubted and constant hereditary transmission than to any peculiarities of climate. Parties proposing for assurance, aware how much an unfavourable family history tells against a life, t ry at times to cover the existence of phthisis by describing it under some other name. Thus a relative is said to have died of " a s t h m a " or "bronchitis," when, on inquiry, the disease is found to have been undoubtedly con- sumption; and the very convenient expression, " died a t " or "soon after childbirth" is constantly used, where the death has

By DR. A. W. FooT. 201

been from some constitutional malady--" dying in childbirth" proving on inquiry to mean after some weeks, and "soon after" to mean several months subsequent to that event. A knowledge of how rapid is the progress consumptive disease often makes after delivery gives an air of reasonableness to the death being attri- buteA to the processes of childbirth. T h e Registrar-General's oifice presents a means of, verifying the cause of death which has not hitherto been systematically turned to account in inquiries connected with life assurance. As with consumption, so, when there is a strain of insanity in t he stock, the examiner must be on the watch for outcroppings of the flaw or fault, speciously veiled in the family history under such doubtful terms as " nervous depression,' .... nervous debility," "hypochondriasis," "cerebral con- gestion," or even a liability to "frequent headaches." When a proposer, descended from an insane parent or parents, or with one or two of his immediate relatives so affected, has a family history spotted ~vith such neurotic blots, it will be advisable to decline the life2

The medical examiner should be on the qui rive in respect of any suggestion as to the necessity of examining the rectum. Many cases have occmTed in which insurance companies have lost money, after a short period of insurance, by tim neglect of this method of examination, b Dr. Edward Hamilton, in his "Clinical Lectures on Diseases of the Lower Bowel," mentions a case recorded by Dr. Allingham of a gentleman who was about to be insured at ordi- nary rates, owing to his healthy aspect and the normal state of all his organs, when the history of some bowel trouble led to an examination of the rectum, in which cancer was found to exist beyond question, e Cancer of the rectum does not show the same tendency to hereditary transmission insisted on for cancer in other situations, and the symptoms may also be so completely suppressed that it may for a long time elude the notice of the patient himself, his friends, and his medical attendant. Bearing on the latency of cancer of the rectum, there is an instructive case recorded by Hilton Fa~ge. a An old woman died in Guy's Hospital, and he discovered three turnouts in the brain, or in its membranes, from whose appearance (columnar epitheliomata) he felt convinced that

a Assurance Magazine. ~rol. VI I I . , p. 334. b See 1V[ed. Press and Circ., 12~h June, 1889. P. 629.

Dubl. Jour. Med. Science. u L X X V L , p. 69. l~ract. Med. Yol. I., p. 103.

202 On the _~[ecllcal Selectio~, of Lices for Ass,tra~zce.

they must be secondary to a primary growth elsewhere. But he searched every part of the body in vain, until at length he happened to notice that the extreme lower end of the rectum had not been taken out with the rest of the intestine. This, when removed, was found to contain a large ulcer, with prominent fungating edges, which was evidently the lesion he had been looking for, although it had given rise to no symptoms during life. Even tha administration of enemata had failed to lead to its discovery. One may well exclaim with Ovid, "Felix I quem faciunt aliena pericula cautum ! "

The previous acceptance of a candidate in another or in the same company must not tempt the examiner to relax his vigilance. In the lapse of time since a previous examination the personal habits of the applicant, the development of some hereditary tendency or constitutional disease, or the occurrence of some severe illness or accident may have changed the conditions of the risk, and have affected the eligibility for assurance. As in a bo~d fide consultation on a private "patient the fresh adviser generally examines for himself, and forms his own opinion on the case, so ought the examiner of a company treat a candidate who may have been accepted by another company.

In regard to "habits," a young examiner is apt to be satisfied with the stereotyped answer, " strictly temperate." But there is no phrase as to the meaning of which opi~lions differ more than that of "str ict temperance." The proposer's idea of what is strict temperance may differ from that adopted by the company, and an answer, truthful from his point of view, may appear the opposite from theirs. The fault generally lies in the wording of the ques- tion. The law requires material facts to be disclosed, and questions asked to be truly answered; but if the questions seek information not about facts, but about matters of opinion, it seems fair to throw on those who seek to show the answers were untrue the onus of proving the answer did not agree with the opinion of those who made it. The medical examiner should, by a series of questions, put with professional tact and ~vith seeming indifference of manner, elicit information as to the quantity and nature of the spirituous liquor imbibed, whether he is in the habit of drinking before meals, or upon an empty stomach, and whether or not his occupation peculiarly exposes him to temptation. A good mode of inquiry is--" What is your usual beverage--beer, wine, or spirits--and their general amounts ? Do you take any spirits in the forenoon ?

By Dr,. A. W. FooT. 208

Is that a habit ?" To prevent trouble, it is worth while to inquire specifically what the proposer drinks, how much, and when. I t is difficult to define in words what constitutes "intemperance," and this all'lenity opens a door to much discussion and diffe~nce of opinion. Thus, in the 6asc of Southcomb v. Merriman, the medical man admitted that the insured had had several outbreaks of intemper- ance, which he did not state, because he thought they had no influence on the health of the applicant. There was a verdict for the plaintiffs (executors of the insured), but a rule for a new trial was obtained; yet twelve witnesses proved the applicant to have been very temperate, and twenty-one that he was the reverse, a For insuran.ce purposes the true question is, not what constitutes intemperance generally, but, is there reason to believe that the applicant takes more alcohol than his constitution will bear ? In insurance cases the physician must consider the word "intemper- ance" as a habit prejudicial to the life of the special individual, and not in any broad and general sense. I f one man drinks a glass of wine daily, and it makes him intoxicated, he is intemperate if he continues to drink that one glass of wine. But if another man drinks six glasses daily, and they have no bad effect on him, but rather the reverse, he is not an intemperate man even if he continue to drink six glasses daily.

The effects of intemperance exhibit themselves chiefly at a com- paratively early age, the maximal rate of mortality in such lives occurring between 41 and 50, so that a person who at that age gives evidence of habitual temperance has escaped one of the most prevalent causes of structural degeneration. Viewed in their relation to acute disease, the behaviour of intemperate people under pneumonia is suggestive of their unfitness to be p:ofitable lives for an insurance company. The Report of the Collective Investigation Committee on Pneumonia, although only provisional, brings out the fact that the deaths from croupous pneumonia among total abstainers wdre 11"1~ per cent. ; among temperate persons, 18"~ per cent.; and among the intemperate, 40"5 per cent2 An explanation of this high death-rate which is offered is the inability of intemperate persons to sustain the prolonged calo- rlfication of this disease--a view which is borne out by Col. Sykes' observation ~ "that, where one teetotaller is cut of[ in India, four

Tidy. Pmr~ I. P. 399. bBrit. Med. J'our., Dec. 1st, 1883. P. 1080.

Assur. M~g. Vol. VIII . , p. 331.

204 On tlte Medical Selection of Lives for Assurance.

intemperate men lose their lives. The susceptibility of drinking men to insolation is well known, and I would just note in passing that, in the medical history, an attack of delirium tremens is not unfrequently entered as "a touch of sunstroke." Verbum satis sapienti.

There are other habits besides those of drinking which prejudice the value of a life, though perhaps not to an dqual extent--for example, the use of opium, or tobacco, or even vegetarianism. These matters should be ascertained and duly weighed by a sagacious examiner. His doing so will at least prevent objections on the part of a captious company, and obviate possible discussion at a future time. I t is not to be expected that the applicant will reveal them unsolicited. Bearing on this point is the dictum of Lord Mansfield--" The insured (proposer) need not mention what the insurer (examiner) ought to know, what he takes upon himself the knowledge of, or what he waives being informed of. The in- surer (examiner) need not be told general topics of speculation. ''a And Lord Denman held that a proposed insurer (applicant)was not bound to volunteer statements of all sorts of things ; but he was bound to conceal nothing when asked, and to answer all ques- tions truly, b

In reference to urinary examination, the change which has taken place in cases of life assurance is little less than a revolution. Brinton, writing in 1856, says, with respect to the urinary ap- p a r a t u s - " Careful inquiry will often give us so healthy a history of its function as to allow us to dispense with all further examina- tion, not only of the organs themselves, but even of their secretion. I t is only where gout, scarlatina, dropsy, or some other disease or appearance of a like suspicious character specially directs our research towards these structures that we need alarm or annoy our subject of examination by insisting on any further enquiry." About the same time (1857) Dr. George Johnson ~ was appointed medical adviser of the Equitable Life Office, an appointment which he held for a period of eighteen years. Soon after his appointment lie wished to arrange for testing the urine of every applicant for insurance ; but the directors objected that this would cause annoy- ance and give offence, and they begged that he would test the urine only when he had reason to suspect that something was

~Taylor. ~Ied. Jurisprud. P. 1156. b Tidy. Op. clt. Par~ I., p. 399. r Brit. 1VIed. Journ. Yol. II., p. 419. 1889

By Dr,. A. W. FOOT. 205

wrong. He had to submit to their decision, lint he told them that the result would be the acceptance of an uncertain number of lives with latent albuminuria.

Later on, Dr., afterwards Sir, E. Sicveking, ~ in 1874, contends that as no medical man reports on a case for life insurance without examining the thorax, so no report for llfe insurance ought to be considered complete without a definite statement as to the condition of the urine after examination by the physician. At the present day the leading oi~ces, so far from regarding examination of the urine as a proceeding calculated to offend or annoy their clients, take good care to see that their rules on the subject are invariably complied with, even in ordinary cases; and I have had the papers returned to me, and have had to have a second interview with the proposer, owing to my not having tested the urine for sugar and albumin in a case in which it proved to be, as I had anticipated, perfectly normal.

Owing to the increasing frequency of systematic and accurate investigations of the urine the knowledge has been acquired that albumin is often found when there is nothing in the state of health to lead to a suspicion of its existence. The subject of such albu- minuria may be completely ignorant that anything is wrong with him. For example, a gentleman whose albuminous urine was rendered nearly solid by nitric acid spoke to Dr. George Johnson in substance as follows : - -" I have come to you at the urgent request of my medical attendant; but I am perfectly well, and I want neither advice nor medicine." b

For many years past the fact that albumin may be abundantly present at one period of the twenty-four hours and entirely absent at another has been publicly demonstrated, and ought to be generally known. This recurrence of albumin occurs day after da); in exactly the same sequence. At the period of rising in the morning there is no albumin to be discovered. In an hour or two's time albumin shows itself, increasing in quantity for a while, and then, as the day advances, declines, and becomes usually entirely lost before bedtime is reached. Remaining absent during the night, it returns after rising the next day, and subsequently follows the same order that had been previously observed. Such cases are called "cyclic" by Dr. Pavy. And this condition may

Medical Adviser in Life Assurance. P. 152. b BriL ]Vie& Journ. Yol. II . , p. 419. 1889.

206 On tlte Medical Selection of Lives jbr Ass~lrance.

run on ~dth its repeated diurnal variation for weeks, months, or years without anything fur ther becoming noticeable. ~

To ascertain tha t a case of albumlnuria belongs to the cyclic genus it is manifestly necessary to test the urine, not only after rest in bed and before breakfast, but also during the day and after food and exercise.

There is another group of cases of albuminuria in apparently healthy persons, in which a notable quantity of albumin exists, and is always present, when no history of nephritis can be elicited, no casts of tubules discovered, and none of the cardio-vascular symptoms of Bright 's disease recogmised. Dr. Pavy says tha t he would look favourably upon such a case only after it had been raider distinct observation for a considerable time without anything wrong becoming developed, and even then he would consider that ~t decidedly more than ordinary risk existed, b

I t would only be very inexperienced examiners who would fall into the mistake of thinking lightly of " a mere trace of albumin." The granular kidney is the form of renal disease especially asso- ciated with small amounts of albumin, and their attention should have been attracted to the coincident conditions of this a f fec t ion~ namely, increased quantity o f urine, low specific gravity, and morbid changes in the cardio-vascular system. The granular kidney is constantly shadowed by death from urmmla, from cerebral hmmorrhage, or from inflammatiofi of the serous membranes.

These cases of latent albumlnuria--a term, I think, not open to the objections which affect the terms temporary, functional, or physiological stand in quite different lights prog~mstically, accord- ing as they are regarded as insured or uninsured cases. An albu- minuric who has been accepted by a company, and who feels and believes himself to be quite well, and knows he has made provision of some kind for the future, is not as likely to take care of himself as an uninsured, whose rejection has perhaps led to his knowledge of a screw loose where he never suspected it. Frequent medical advice will probably be sought by the latter in trivial ailments, for which the former would scorn it. Dr. Johnson ~ has expressed a decided opinion that temporary albmninuria, even when traceable to food, or over-exertion, or exposure to cold, will, if neglected, sooner or later lead to persistent albnminuria, and to fatal disease

Brit. ]~ed. Journ. Vol. II., p. 418. 1889. b :Brit. Med. Journ. Vol. II., I~. t18. 1889. c Bri~. Med. Journ. Dec. 1879. P. 928.

By DR. A . W . FOOT. 207

of the kidneys. Thus, I do not think the prognostic rules for carefully watched albuminuria will apply to those who are careless and indifferent about an affection which does not trouble them, and hence I would fear that an optimism as to the results of latent albuminuria derived from the results of well-attended patients in private practice might lead an examiner to take a too lenient view of albuminuria when the question of life insurance is involved. The private practitioner or the consultant can afford to make a more favourable prognosis of albuminuria in apparently healthy persons if they ~ro to" have thei.eontinual superintendence of obedient and intelligent patients; but the medical examiner of an insurance company who passes an albuminuric life is rather in the position of a station master who lets a train move Oll with the red lamps against it. Albuminm'ia is always serious, though it may not always indicate organic disease, and in this respect it has ~

ve ry apt resemblance to hsemoptysis. The presence of albumin in the urine, unless when "extra-renal," is always pathological, whether we can detect the nature of the pathological change or not. Albumin present in the urine even casually must be regarded as a danger sigaml.

I t is quite true, ]eavlng insurance business aside, that some albuminurics may live a long time, even outlive people with per- fectly normal urine, providing they comply with such conditions as (1) no history of BrighFs disease in a parent or in any two near relatives; (2) no personal history of past acute nephritis; (3) no history of plumbism or gout ; (4) no cardiac hypertrophy, hard pulse, frequent nocturnal micturition, or retinal changes; (5) where the age is not over 40; ( 6 ) , . ~ the urine does not deposit casts; (7) ~ t h r e is no cl~ronic dyspepsia; but such lives belong to the class called risky, and the acceptance of risky llves is too speculative a business to formulate general rules for. I t is a significant fact that Mr. Eales, of Birmingham, found retinal changes in five out of fourteen cases of supposed temporary albumlnm'ia in persons between the ages of eleven and twenty- eight. ~

The only insm'ance company that is known to have inquired into the subsequent state of health of persons whose lives had been declined on account of albuminm'ia is the United States Company in New York." Among ~hose who made applications to that office

Birmln.gham 3$edlcM :Review. 1880. b Hilton Fagge. Prac~. of Med. Vol. II., p. 2601.

208 On tl~e Jl~edical Selection of Lives for Assurance.

in the three years, 1878-80, there were sixty-nine (or from 10 to 12 per cent. in each year) whose urine was found to be albuminous�9 Before the end of 1880 four of these persons died, and it is stated by Mr. 1V[unn, one of the medical officers of the company, that the "general appearance of the majority of the others who had been under observation for more than a year was gradually dete- riorating." The results of this investigation shows that an insu- rance company runs a great risk if it neglects to have the urine of all applicants tested.

A t a meeting of t h ~ ( i ~ t i o a of Am.~a~n Physicians, held in Washington in 1888, Dr. Tyson, of Philadelphia, a well-known writer on renal diseases, formulated the conditions under which he considered albuminuria might be regarded as not constituting -t formal ground for exclusion in life assurance. These conditions are--1. That the applican t presents in all other respects the signs of good health. 2. That the albuminuria is unaccompanied by tube casts. 3. That the quantity of albumin does not exceed one- fifth of the bulk of the specimen of urine examined. 4. That the albumin is absent on ~ g in the morning (this is not essential). 5�9 That the density of~l~e total ~ e ~ - f o u r hours is not under 1015. 6. That signs of cardiac hypertrophy or high arterial tension are absent�9 7. That the applicant is not over forty years of age. 8. That gout in any shape is not p~esent. 9. That retinal changes are absent. But he qualifies all this by. the statement that there are few medical examiners competent to make such an examination as these conditions would imply~ Whether this is so or not, I think that for this generation, at all events, the traditional notion should hold ~ a t the presence of albumin in the urine, unless clearly e x t r a ~ a | , 1 ~ o u l d b e i ~ t h o u t further ques- tion, as excluding the case from acceptance by llfe insurance companies.

In examining the urine it is well to bear in mind that it should in all cases be tested for sugar regardless of the specific gravity. I t is only by routine examination of the urine that the early stage of diabetes mellitus can be discovered, when the quantity of glucose is insufficient to raise the specific grtvity much, and it is to be borne in mind that glycosuria, or the transieat occurrence of sugar in the urine, may at any time pass into c o ~ e d diabetes�9 If there appears to be any i a ~ of sugar in fhe urine, the family history should be closely scrutmmed; for dmbete~ comes next to rheumatism in frequency of heredity. Diabetics are ineligible, because, although

By Da. A. W. FOOT. 209

some cases live long, the ultimate result is always disastrous. In fact, a diabetic patient may be aptly compared to a tower under- mined--its downfall is assured, but none can certainly tell when the catastrophe will occur. The quantity of urine obtainable is often insufficient to float the urinometer freely. In such a case the urine may be diluted with distilled water, and the last figure of the specific gravity of the mixed fluids multiplied by their united volumes. Thus, i f we-add to half an ounce of urine one and a half ounces of distilled w ~ e ~ gad :the specific gravity of this mixture is 1,007, then 7 multiptled~l~[,4 gives the specific gravity of the unmixed urine as 10282

I t might seem to many that the d~gps~i~ of such a subject as the acceptance of cases of damaged, l a ~ is preposterous aml irrelevant, but the readin~ of Si~A. i~ht~ka~ paper at Brighton (1886) on Cases of Valvular Distmse a ~ l~eart, known to have existed for over Five Years without ea~t~l~ Serious Symptoms," ~ has raised the question in a very practical manner. This remark- able essay was based on notes of 634 of 1~ ~ 'va te patients by Sir Andrew Clark, wh0 : !~ t l ~ ' a a ~ o k s i~o ~ retort of criticism, and has given us the,,benefit of the distillate. The result of the analysis goes to show, that there exist multitudes of persons with chronic valvular disease: of the heart, who not only suffer no inconvenience t h e r e f r g m @ ' u ~ also ~2able of discharging the duties and enjoying the l~eas~S of life,

The first of his cage~ 2may be quoted at length as a type of the class referred to. In the early part of 1842 the house-governor of o.ne of ~he largest London hospitals,, l~iil;g about to re.arty, petitioned t]~e commit~t~ far ~ h ~ m h ~ to. dwell with his wife, and proceeded to insnre:liiS:~e. The office refused to accept the insurance upon any terms, and in reply to the urgent questions of the candidate, who averred that in the whole course of his life lie had never been ill, said that he had a seriogs ~lisease of the heart in the form of mitral regurg4ta~n, T~t~hefurther question of the proposer whether he wouklli,~e six months, the reply was that he might. Then the h o ~ e r n g r , with the characteristic inaccuracy of patients, i n f ~ r m ~ t ! m ,~Qmmittee that he had a mortal disease of the ]1c~ ~ ~ h~ ~.41~1~ ~u six nlonths, and that he withdrew his apll~i'aat~on f ~ ~ ' ~ ' ~ o m m i t t e e con- sidered the matter, and f~r lng tha~ ~ ~ 4 t n o r might die

~Ralfe, Di~Of t l roKidao~ 1 ~. g~. Brit. ~VIed. J~*~i. ~rol. E, p. 260. 1887.

P

210 On the Medical, ~el~etion of Lives for ~lss,rance.

suddenly [11 the wards, they superannuated him; and furthermore, believing that he had but a short time to live, they superannuated him on full pay. In 1854 this gentleman consulted Sir A. Clark for indigestion, who discovered that he had a loud, rasping, systolic murmur, heard not only in the mitral area, hut all over the left side of the chest. Beyond the symptoms of indigestion, he exhibited no other evidence than the inurmur of the existence of cardiac disease. Without being particularly careful, he continued to hve, work, and e n ~ ~ ~ . ] . 8 7 4 , when, at an advanced a~e, he died of an attack' ~ . a ~ t e Vbr0nchiiii~. T~hus, for thirty-two years after having been condemned to die of heart disease, he continued to enjoy mare than average hcalth, to discharge the duties of a town rectory, and to draw his full pay from the hospital.

The conditions of a favourable prognosis differ for differei~t valves, and for each valve according to the character of the lesion. A comparatively small "loading" might justify assurance in a favonrable case of mitral regurgitant disease, whilst no "loading," however heavy, for a ' ~ e h o w e ~ m . ~ : w o ~ l d warrant accept- ance of a case of regurgltant dlsease'0F,~'-t,~he .aortic valves. I f in the former case the risks to be incun-ed were to be reckoned as one, then in the latter., case the r~s~. to l~r would have to be reckoned as a th~us~d. The : ~ z w l t h aortic might possibly live as long as the perso~with m t t ~ U ~ s e , but there would be such small security for the t r a n s a c t i O n S , considering the possi- bilities of disaster, it could not be considered as other than a reckless speculat~oa~ ~

The eonditlons ~ i ~ ' ~ r experlence and judgment of Sir A. Clark, would justify a e~'Oi~'mitral regurgitant disease in sustaining an application for life assurance, are as follows, assuming on the part of the patient obedience to properly-adjusted rules of hea l th :~ (a )Goo~ene ra l . i hea l t l~ ; (b) just habits of living; (c) no ~ x ~ l l i ~ i l ~ ' ~ rheumatic or to catarrhal affection ; (d) " 0 r i g f ~ t h e ~ a r lesion independently of degeneration; (e)exls~nco of t ~ y ~ l a r lesion without change for over three years; ( 3 ~ ) : ~ ~ s of moderate frequency and general r e g ~ ~ ; , ~ m m l ~ l arteries, with a normal amount of vessels;q0 free course of blood t h r o ~ e i n ~ r e e d o m from pulmonary, hepatic, and r ~ x i ~ ~

Brit. Med. Journ. Yol.~][~r 871. 1887:

By Dn. A. ~V. FooT. 211

There are several objections which at once present themselves to the acceptance of damaged hearts, although we probably each know that a creaking pump is capable of many years of moderate wear and tear. Sir A. Clark himself admits ~ that he has nothing to do with any life assurance office, though he frequently has submitted to him cases for arbitration. As in the cases of latent, albumlnuria, the comfortable or wealthy classes, who are inde- pendent of a prospective provision for their families, are in a different category as to prognosis from those who, damaged as they are, having passed a medical investigation, believe themselves sound, knowing and feeling nothing to the eontrary. These latter eat and drink, and do things they would not do if they knew they were wMking along the brink of a precipice. Looked at from the point of view of fife insurance company, the thing to be considered is not so much the value of the individual'life, as the value of a mass of such lives compared with a mass of lives without this damage, and viewed from this aspect the office that accepts a life with an organic heart-murmur runs a risk at present not calculated for in its rates. Some years ago an office of high repute b made an experiment of taking lives with heart-bruit, but otherMse in good health. This office, however, in a few years discontinued the practice, as it was found that the lives most largely insured fell in before their expectancy; anti though by reason of the heavv loading, the office might not ultimately be a loser on the total of these lives, yet enough damaged lives did not present themselves to form a separate class which could be calculated for.

Sir 3_. Clark is perfectly logical in carrying his conclusions to their legitimate outcome; but my eontenti0n is that, however applicable these conclusions are to private practice, they are not equally so to insurance practice, inasmuch as iu the.former ease there is at all events a likelihood of continuous oversight of the patient, while irr the latter ease the supervision i i of a casual and temporary nature, while the acceptors of the risk remain helplessly saddled with it. I t is now generally accepted that Laennee, and subsequently the pathological school, greatly exaggerated the un- favourable prognostic value of heart-murmurs. We must always be careful not to over-estimate ~he importance of the murmur as a fact, nor to pay, too much ~ to the me~ existence of ~he sound and too little to the circumstances in which it occurs, iVlany

Brit. 5Ied. J0urn. "q'oL h P. [18 c2. 1887. b Bri~. ~r Journ, Vol. I., p. g39. 1887.

212 The Lesions of tile Tfiroat in Leprosy.

a case of chronic valvular disease goes on for a long time, provided compensation~which may be taken to mean accommodation of the muscular power of the heart to adverse circumstances--occurs. But compensation is rather a condition to b~ hoped for than a reality procurable at will. There are no means by which, in any recent case, its advent can be foretold with certainty. When secondary symptoms postpone their appearance we are willing to assume compensation has taken place, but we can neither guarantee its arrival nor insure its permanence.

The opinion that an applicant with damaged mitral valve can be accepted by an insurance office is probably one rather too far in advance of the present practice of the various offices to be judi- ciously acted on. As it cannot be denied that even the least amount of valvular disease of the heart real/prevent a man from living out his expectancy, it is only right that the insurance company should have the benefit of the doubt, and not the applicant. Even sup- posing, first of all, that the mitral disease shall have existed inde- pendently of degeneration in the heart; secondly, that it shall have existed for two years ; thirdly, that tha ventricles shall be in good order; fourthly, that the arteries shall be sound; fifthly, that there is no persistent basic congestion, or recurrent hepatic stasis; that the patient should not be liable to colds which hang about him; and, finally, that his general health shall be good, within which limitations Sir A. Clark ~ is prepared to say that the mitral disease will not shorten life--the application of this doctrine to life assurance would require very great discrimination, and would be a dangerous one to inculcate anmng any but the most highly informed and most careful examiners.

ART ]X.--The Lesio~s of the The.oat in Ze2)rosy. By JotI~ D. I-hLLIS, F.R.C.S.I.; M.R.I.A.

1 HAVE recently had the opportunity of examining with the laryngoscope the throats of over one hmldred persons suffering from the different forms of leprosy, the notes of whose cases are in my possession. A synopsis, in tabular form, has been published in the Journal of Zaryngology, but it has been suggested to me that a fuller clinical account might be of interest at the present time, when everything relating to the subject of leprosy is exciting so much attention at home and abroad. This is owing, doubtless, to

RBrit. ]~ed. Joura. Vol. I., p. 382. 1887.